Meet the Presenter… - pmiMD.com · 2018-08-22 · WHAT YOU NEED TO KNOW TO PROPERLY INVESTIGATE...

Welcome to PMI’sWebinar Presentation

Brought to you by:Practice Management Institute®

pmiMD.com

On the topic:

Coding and Auditing Telemedicine Services

Meet the Presenter…

Aimee Wilcox, CPMA, CCS-P, CST, MA, MT

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W H A T Y O U N E E D T O K N O W

T O P R O P E R L Y I N V E S T I G A T E

Coding and Auditing

Telemedicine Services

Aimee L. Wilcox, CPMA, CCS-P, CMHP, CST, MA, MTDirector of Content - Find-A-Code

Practice Management Institutewww.pmiMD.com

Webinar/Audio ConferenceAugust 8, 2018

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Is Telemedicine the Answer?

20% of Americans live in rural areas served by 9% of healthcare providers with less access to specialists (Alaska)

Technology is available (NASA)

Payers are quickly climbing aboard (50 options)

New issues with multinational corporations (EU)

Evolution of Telemedicine

1879 Lancet article suggesting telephones were the future between provider and patient

1948 x-ray images sent via telephone between West Chester and Philadelphia PA (24 miles)

1967 Miami Fire Department transmitted ECG from units to Jackson Memorial Hospital (now

commonplace)

1963-1980 Massachusetts Gen Hospital (MGH) telecom link between nurse clinicians and the airport interactive TV microwave link for ECG, stethoscope, microscopy, voice, etc. established telepsychiatry link with the VA hospital

60’s & 70’s NASA - U.S. Indian Health sponsored Space Technology Applied to Rural Papago Advanced

Healthcare Satellite-based communications to provide medical services to astronauts and residents of

an isolated reservation.

Now…



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Telemedicine Today

Telemedicine Today

Increased bandwidth Better security HIPAA compliant cloud-based storage/encryption Direct save to EMR and patient portals Copies primary provider Connects and transmits directly (live) or deferred

(remotely) Options for smart facilities, kiosks, communities,

apartments, homes for seniors and other populations In-medication sensors, wearable technology integration,

and …whatever you can think of Promotes medical record sharing (reducing costs for

duplicative services) and promotes interoperability



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Benefits

PROVIDER• Reduction in ER, Urgent Care, and Retail Clinic visits (71% unnecessary)• Reduces no shows & increases patient compliance. • Provides access to specialist care not otherwise available• Improved documentation as linked to EHRs• Providers keep money and control in office rather than elsewhere

INSURANCE• Telemedicine is about 50% cheaper• Specialty care available through primary provider direction and location.• Patient compliance• Reduction of expensive ER, Urgent Care, or Retail visits.• Immediate emergency directives to correct care provider at time of injury

PATIENT• Reduces patient expenses (work, travel, driver, family, Uber, or assistance)• Reduced stigma in rural communities• Less wait times (in office and for appointment availability)• Lower price• Access to specialists not otherwise available; educates and promotes awareness

Terminology

Synchronous communication (real time): Uses interactive audiovisual equipment for video conferencing (immediate)

Asynchronous communication (store-and-forward): Uses recording devices to record for provider to see and respond to later. (video, images, data)

Remote patient monitoring: Allows a provider to track important patient data after they’ve been released home or to another care facility, potentially reducing the need for readmission. (pacemakers, cardioverter-defibrillators, etc.) Holter Monitor

Originating site: The location of the beneficiary (patient) at the time of the telemedicine service

Distant site: The location of the physician/QHP at the time of the telemedicine service

Telehealth parity laws: Require payers to reimburse telemedicine services at same rate as in-person or on-site services



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Who Governs?

In the United States, laws and regulations at both the federal and state levels affect the success and future of telehealth services

Federal: Medicare Determines rules for performance, documentation, reporting, and payment and pays the same for telemedicine as it does for in-person services (parity laws).

States: Medicaid, W/Comp, & CommercialEach state determines the laws & parity laws that governtelemedicine

Auditors must follow federal guidelines for Medicare and state guidelines for Medicaid, Private payers, and Workers Compensation

Parity Laws

American Telemedicine Association: • Parity laws are in place (33)• Proposed parity bills (8) • No parity legislative action (8)• Partial parity laws (1)

Auditing is about knowing the rules

– but the parity laws vary from state to state

and several don’t have any in place to follow.



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Medicare

All Medicare beneficiaries are eligible to receive telemedicine services if…

o They present to an approved originating siteo In an approved locationo See an approved, licensed telemedicine providero Have an approved telemedicine serviceo Communicate in real time (live feed) or Remote

Monitoring with specific rules (NEW in 2018)o Documentation is correctly doneo The correct code and modifier is reported

All Medicare beneficiaries are eligible to receive telemedicine services if…

o They present to an approved originating siteo In an approved locationo See an approved, licensed telemedicine providero Have an approved telemedicine serviceo Communicate in real time (live feed) or Remote

Monitoring with specific rules (NEW in 2018)o Documentation is correctly doneo The correct code and modifier is reported

Originating Site

Office of Inspector General – AuditAudited 191,118 telemedicine distant site claims from 2014-2015 and found $3.7 million in overpayments

Originating SitesMust be in a pre-designated Health Professional Shortage Area (HPSA) to qualify.

• A county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

• Medicare tool to verify originating site is authorized.

https://datawarehouse.hrsa.gov/tools/analyzers/geo/ShortageArea.aspx

You can search by address or facility type (dental, BH, primary care, etc.)

Medicare reimburses $25.76 for the originating sitehosting the telemedicine visit.



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HPSA Search

Health Professional Shortage Areas (HPSAs) have

shortages of primary care, dental care,

or mental health providers and may be

geographic (a county or service area),

population (e.g., low income or Medicaid eligible)

or facilities (e.g., federally qualified

health centers, or state or

federal prisons).

Authorized Originating Sites

Enter an address to determine whether it is located in a shortage area: HPSA Geographic, HPSA Geographic High Needs, or Population Group HPSA or an MUA/P.



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Distant Site Practitioners

Approved Healthcare Provider

Subject to state law, the practitioners who may furnish and receive payment for covered telemedicine services include:

• Physicians• Nurse practitioners (NP)• Physician Assistants (PA)• Nurse midwives• Clinical nurse specialists (CNS)• Certified registered nurse anesthetists (CRNA)• Registered dietitians or nutrition professionals• Clinical psychologists (CP) & Clinical social

workers (CSW) (with limitations)

Provider Credentialing

Medicare and The Joint Commission have approved a “privileging by proxy” (distant site providers get admitting/treating privileges at the originating site.

The following requirements must be met:

Both parties have a written agreement

Distant-site hospital must be Medicare-participating hospital/telemedicine entity

The telehealth provider is privileged at the distant-site hospital

A current list of the telehealth provider’s privileges is given to the originating site hospital



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Provider Credentialing

Continued….

The telehealth provider holds a license issued or is recognized by the state in which the originating-site hospital is located

The originating-site hospital has an internal review of the telehealth provider’s performance and provides this information to the distant-site hospital

The originating site hospital must inform the distant-site hospital of all adverse events and complaints regarding the services provided by the teleheath provider.

Approved Services

Check the Telehealth Services Fact Sheet

There are over 180 approved Medicare telehealth services.NEW - As of 2018, Medicare has approved the following additional services for telehealth:• G0296 Visit to determine low-dose computed

tomography (LDCT) eligibility• 90785 Interactive complexity• 96160-96161 Health Risk Assessment• G0506 Care Planning for Chronic Care Mngmt• 90839-90840 Psychotherapy for Crisis

Some codes require “in person” or “hands on” visits or have frequency limits (99231-99233; 99307-99310, G0108, G0109)



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Type of Service Transmission

Real-time audiovisual Report CPT or HCPCS with “Place of Service 02 Telehealth”

For 2018, Critical Access Hospital (CAH) Optional Payment Method add GT modifier to service line (pays 80% of fee).

All other telemedicine no longer requires GT modifier

Asynchronous “store and forward” (Alaska & Hawaii) Requires CPT or HCPCS code with modifier GQ. Certifies the

asynchronous medical file was collected and transmitted to you at the distant site from a Federal telemedicine demonstration project in Alaska or Hawaii)


Remote monitoring (NEW as of 2018) Separate payment for remote monitoring using:

99091 collection & interpretation of physiological data Supporting documentation in the record Documentation of testing ordered Symptoms or diagnosis for which it was ordered When the data was received and reviewed Summary of findings/Provider’s interpretation

Additional Rules Limited to 1 every 30 days Once per patient during same service period as 99487, 99489,

99490, 99495, 99496, 99492-99494, 99484 Requires ABN and must be documented in patient’s chart Face-to-Face visit with billing practitioner required (new patient

or not seen in past one year)



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Documentation Requirements include: Date of service (DOS)

Location of provider (distant site)

Location of the patient (originating site)

Names of all participants with individual roles identified

Type of telemedicine service (real time, asynchronous, remote monitoring)

ABNs, as required

The criteria met for the CPT or HCPCS code reported

Diagnosis or symptoms to support high-specificity ICD-10-CM code selection

What Codes Are Reported

Distant Site Practitioners report telemedicine services using the appropriate HCPCS Level I (CPT) or II (National) codes.

Example: 99204-GT for new patient E/M encounter in CAH or 99204 (POS 2) for all others

Documentation should match the E/M level requirements for service reported

Apply the appropriate modifiers to identify the type of telemedicine communication that took place:

GT (synchronous communications) (CAH only as of 2018)

GQ (asynchronous communications)

REMEMBER: When the provider reports the correct code with the correct modifier, they are certifying the components of the service were performed, the originating and distant sites were authorized locations, the provider had the proper credentials and was enrolled in Medicare as a provider. If any one of these things is not true, submission of the claim could be considered FRAUD



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Deductibles and Co-Insurance

Telehealth claims are processed and paid the same (except for rare circumstances) as regular claims.

Subject to: Annual deductibles Co-insurance Preauthorization Correct diagnosis coding NCCI edits Global periods

Key Points to Remember

Providers at the distant site must be enrolled in Medicare

Patient’s home is NOT an authorized originating site (exception -Comprehensive Care for Joint Replacement (CJR) Model)

Some visits have limitations or “hands-on” requirements

If first encounter is via telemedicine, the NP and EP criteria still apply. All the same EM coding rules apply.

The ONLY consultations Medicare pays for are ER or Inpatient telehealth consultations. The telehealth consultant cannot be the physician of record or attending physician.

All documentation requirements must be met in addition to the previously noted telehealth-specific information.



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Medicaid

Individual states hold the power.

50 states = 50 sets of guidelines

Some language is the same but not much (Utah Dept Health – class)

Resources

Visit National Association of Medicaid Directors http://medicaiddirectors.org/ for more information on your state’s requirements.

Interactive Tools

Resources:• State laws• State administrative codes• Medicaid Provider Manuals• Updated biannually)

Centers for Connected Health PolicyThe National Telehealth Policy Resource Center

http://www.cchpca.org/state-laws-and-reimbursement-policies

• Definitions• Reimbursement• Live video vs Remote vs Asynchronous• Transmission/Facility Fee (Originating Site)• Location• Consent• Licensure• Online Prescribing• Private Payers• Additional Findings/Current Legislation



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Overview

Definition (49 States + DC – Alabama)

Reimbursement policies (49+ DC –Massachusetts)/vague

Live Video (49+DC-Massachusetts)

Store-and-Forward (14 states + possibly 3 can’t locate the written policies)

Remote Monitoring (20 states, some policies not found but required by state law)

Email/Phone/Fax (generally not acceptable)

Transmission/Facility Fee (32 states – originating site)

Overview

Location of Service (huge variety) Consent (31 states) Licensure (9 states issue special licenses) Online prescribing (require questionnaire or physical

exam 1st) Private Payers (38 states + DC have laws) Additional (Maryland/WA) hearing impaired, WA –in

person visit w/in 60 days of telemedicine visit), etc.

CURRENT LEGISLATION There are 44 states with 160 telehealth-related pieces of legislation for 2018



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Commercial Payers

Anthem Blue Cross

Coverage

Location

Format

Notification of primary care

Types of services

CPT/HCPCS Codeso Online policies

o Preauthorization

o Documentation

o Deductibles

o Coinsurance

o Types of Services

Workers Compensation

Pros

Cost benefits

Reduced time off work

Reduced travel

Faster recovery

Better triaging

Access to specialists

Cons

Type of service (smart phone chats w/o medical personnel

Failure to pre-authorize

How video conferences can be used in claim hearings

Exams at the center of the dispute will increase

Carrier MD not allowed telemedicine only in-person examinations

Overutilization & abusive practices

Insurers to file complaint when suspect abuse

Standards of care same as in-person

Documentation issues



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Overview & Questions

Need a third-party review, customized training, advice with a fraud case, or

certification prep? Let Us Help!

Aimee Wilcox, CPMA, CCS-P, CST, CMHP, MT, MATo Schedule Your Audit or Training

contact Aimee at 801-874-7365 or via email at: [email protected]



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Meet the Presenter… - pmiMD.com · 2018-08-22 · WHAT YOU NEED TO KNOW TO PROPERLY INVESTIGATE...

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